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<br />WHEN THlS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH,/C�VD HUM!.A�
<br />SYSTEM,IT CFRT►FlES THE BELOW TD BE A TRUE COPY OF THE OR1�/NAL RLC`i,�RiQ ON
<br />THE NEBR�4SKA HEALTH AND HUMAN SERV/CFS SYSTEM, V1TAL STAT/S�ICS �ECt�'/OA
<br />' THE LEOAL DEPOS/TORY FOR VITAL RECORDS
<br />DATE OF /SSUANCE ' ' 1� �
<br />�����
<br />�AN 1 � 200� ass�sr�ai�rrsrarE�
<br />LINCOLN. NEBRASKA HEALTHANQ Hl1Mi�'11f��Q1lIC1
<br />� -,
<br />STATE OF NEBRASKA- DEPAR111�NT OF HEALTH AND H[JMAN SERVICES FiN{�1� �
<br />V1TAL STATLSTlCS -
<br />CERTIFICATE O DEATH , �. ,
<br />--- — _ - -
<br />1. DECEDENT-NAME -- --- -- --- - ' FIRST � MIDDLE — ... LAST � --� - . 2. SIX � �� 3.,D
<br />" Richard Frank Krolikowski_ _ � nnaie
<br />4. CIN AND STATE OF BIRTH lBnot tn fJ.SA., neme cor�ntryJ Sa AGE , Last Bird�day UNDER 1 YEAR UNDER t DAY 6.
<br />IYral Sb. MOS. DAYS Sc. HOURS' MINS.
<br />NEVER
<br />Ashton, Nebraska gg � February 3, 1918
<br />7. S�CURTIY NUMBER -- - . _- _ -- - . .- _� :_ 8a PLACE OF DEATH � - - - --- .— -- - . -- - - - -- — -- - - �--
<br />507-16-8709 I r+osarra� ❑ mo�amn oniex � N�,�, r+o�
<br />80. FACILITV �- Nama .�--- /Hnot rnsOtWerb glve s6ee! and nionber) � ER 6utpetlent � Residence �
<br />St. Francis Medical Center Ivl DOA � om�rs�Gr�,
<br />7*r
<br />- = - — - — _ -- - -
<br />8c. CITY. TOWN OR LOCATION OF DEATH � { Bd. IN31DE C(TY LIMITS Be. CAUNTV OF DEATH -
<br />1- _. __a-- -- - -- - - - -
<br />- �ranu isiana oisisui _. -- - — — v� [�x '� - Hall
<br />-- — -
<br />9a RESIbENCE - STATE Bb. CAUNTY 9c. CITY. TOWN OR LOCATION � 9tl. STfiEET AND NUMBER (GidudfigZlP Cadel 9e INSIDE CITY LIMRS
<br />Ne braska �_ _ Hail _ Wood River 305 East Street 6888 Y� � No ❑
<br />10. RACE -(e.g., WMte. Bleck. Ameri�an Indian- 11. ANCESTRY le.g. Iffiflan, Mexican. Ge
<br />�.i �s�r,n �e � rsP �''� Polish
<br />14e. USUAL OCCUPATION /Give k/nd of wak done dwlRg mast 14b. fQND OF
<br />af wnridrtg 1Ne, even 8refiedl I
<br />Farmer/Fumigator L
<br />t& FATHER - N/1ME FlRST � � A4IDDLE LAS7
<br />Peter Krolikowskl
<br />-- ----
<br />1fl WAS DEC�ASED EVER IN U.S. AflMED FOFiCE57 �--
<br />n � NO �� I in�. � war e�ro ame� m����
<br />�R�9�d� ��.�'� '
<br />1L��#I# -- � , ,
<br />�HfCI�lS � --
<br />��� - =
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<br />r, � ` �-T��� � �. :
<br />: oe oenni (r�a�m. aey. re�1 - - —
<br />December 30, 2004
<br />1TE OF BIRTH /ManC�. Oay. Year)
<br />Agriculture/Pest Control
<br />19b. INFORMANT MAILINO ADDRESS ISTREET OR R.F.D. N0. CITY OR TOWN. STATE ZIP)
<br />305 East Street Wood R iver, Nebraska 68883
<br />20. EM AL ER -( iNA' 8 UCEPI O. � �� 21a MEfH00 OF DISPOSITION 21b.
<br />_ � _ n.�����,<,�_��d I � � ❑ �,�,
<br />zze. Fuy¢Ra� t�o�a"� � iSnnnsv"a+v - - ° . z, a
<br />�� Apfel Funeral Home I❑ c� ❑ o�
<br />Maggie Idos
<br />D oris Krolikow
<br />E � 27a CEMETERY OR CREMA70RY NAME
<br />Jan 3, 2005 T� Westlawn Cemetery
<br />Grand Island, Nebraska 688U1
<br />._... �,.,.���,,,w�,.����� ��,..��,.,,�.�.�.,,_,.��,,.�,,,..rv.��,.��.�,
<br />}
<br />411 West 11th St. P. Box 1 Wood River, Nebraska 68883
<br />23. IMM TE CAU � fENTER ONLY� CA SE PEA LINE FOR�la6 (bJ. AND (e�� � - I I�rtervel betwaen onset eml deazn
<br />PART I . �. /+ � � � �/ ��� � tJ�.� Y `C ��� j "7' Y V ` ' �
<br />� ✓v
<br />DUE TO, OR AS A CONSEOUENCE OF �� � � 1 � I I�rterval behreen onset a� tlBath
<br />— -
<br />rol � ��l ��" � � L �.'"'j �°�. C: ��(A�f�Yl�y t" Y " �� i 1 Q.`�-� -
<br />°---__
<br />-- -- - - - - _ — - - — -- --- —
<br />DUE TO.OR AS A CONSEOUENCE OF: - I 6rterval between onset aiW tleath
<br />��� � .
<br />- '- --- _ _
<br />P � OTHER SIGNI� �O� �(tlo � rtg to t�; r eAh� ��� PART IU IF FEM1IALE WAS THERE A -.. 24 AUTOPSY
<br />� 1��� S qo PREQNANCY IN THE PAST 3 MONTHS?
<br />--- '\�CJ` IAges 10-54� Yes No Yes No
<br />❑-.--- �_ . _ �_.
<br />ZBa � �- 28b. DATE �JIV,� 1��/Ma Oay. Yr.J 28c. HOUR OF INJURY 2Bd. DESCFlIBE HOW WJURY OCCURR�
<br />1
<br />� Accident � UrMatermu�ed � � M
<br />� Suwide � Pending 28e. INJURY AT WORK � 26E PLAa E Q_ �RV / !1t .r1�r, ferm. street
<br />❑ ❑ ofec cWiang, sPacn}•
<br />❑ Hontielde Invesu9� Y� No
<br />27a DATEOFDEATH (Ma.Oay Yr.J -=---- _� --- --� — — -
<br />� December 30, 2004
<br />� � 27b. DATE S(GNm (Ma. Day. YtJ � 27a TIME OF DEA
<br />�� , —S—p S �°��`
<br />8
<br />� 27d. To tlie I�e,ct 0} my Wrowiedge. d occurted � tlffie arM due to the
<br />causefsl smted. � a ,. _
<br />� YES �NO � � UNKNOWN � YES
<br />- . -_ _ __— _ - _ _._ __— __._- __
<br />37. NAME AND ADDRESS OF CERl7FIEH (PHVS(CUW, CORONER'S PHYSICUW OA COUNTY ATTORNEYI ?y
<br />S.L Husen, MD 2116 West Faidley Ave. �
<br />e i
<br />32a. aECisrana - -- � --- - �f �
<br />�8•
<br />2Ba. �ATE SIGNED /6fa Day.
<br />�
<br />���� 2BC. PRONOUNCED DEAD lMa. Day, Yr.l
<br />y a�
<br />���o
<br />EXAMINER OR CORONER
<br />( Y � - - -N
<br />CITY DR TOWN
<br />- --
<br />28b T1ME OF DEA'fH
<br />ZBd PRONOUNCED DEAD /Hnurl
<br />~��� � tha Uma date and � .arM�ro IrnasUgatlon, i�opinion death occurted at
<br />TION BEEN CONSIDERED? 30b WAS CONSENT GRANTm?
<br />� IVO ❑- YES � NO
<br />G `_' r
<br />OrP/infl _ _ — �
<br />�0 Grand Island,Nebraska. 68803
<br />� WIDOWEb 13. NAMEOFSPOUSE lpwde.givemeidenname)
<br />n orvo�o Doris Schnase .
<br />�ameNary a SacorMary 10-t2) Copeg§ 11-0 w 5-I
<br />��„� � � ' �: ��.:
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